Download 1 Epidemic Intelligence and the Technopolitics of Global Health

Epidemic Intelligence and the Technopolitics of Global Health
Andrew Lakoff
University of Southern California
Prepared for the Berkeley Workshop on Environmental Politics
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The movement for global health is an increasingly prominent rationale for action
across a range of organizations, including philanthropic foundations, development agencies,
and biomedical research institutes. Despite the appearance of a shared moral and technical
project, however, global health is not a unified field. Even for many of the actors centrally
involved in the movement, it is not clear precisely what the term entails and how global
health projects should be distinguished from already established national and international
public health efforts.1 Indeed, different projects of global health imply starkly different
understandings of the most salient threats facing global populations, of the relevant groups
whose health should be protected, and of the appropriate justification for health
interventions that transgress national sovereignty.
In what follows I describe two contemporary regimes for envisioning and
intervening in the field of global health: global health security and humanitarian biomedicine. Each
of these regimes combines normative and technical elements to provide a rationale for
managing infectious disease on a global scale. They each envision a form of social life that
requires the fulfillment of an innovative technological project. However, the two regimes
rest on very different visions both of the social order that is at stake in global health and of
the most appropriate technical means of achieving it. While these two regimes by no means
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exhaust the expansive field of global health, their juxtaposition usefully highlights some of
the tensions inherent in many contemporary global health initiatives.
Global health security focuses on “emerging infectious diseases” – whether naturally
occurring or man-made – which are seen to threaten wealthy countries, and which typically
(though not always) emanate from Asia, sub-Saharan Africa, or Latin America. Its exemplary
pathogens include weaponized smallpox, SARS and highly virulent influenza; but what is
crucial is that this regime is oriented toward outbreaks that have not yet occurred – and may
never occur. For this reason, it seeks to implement systems of preparedness for events
whose likelihood is incalculable but whose political, economic and health consequences
could be catastrophic. Its ambitious sociotechnical agenda is to create a real-time, global
disease surveillance system that can provide “early warning” of potential outbreaks in
developing countries and link such early warning to immediate systems of response that will
protect against their spread to the rest of the world. To achieve this, global health security
initiatives draw together various organizations including multilateral health agencies, national
disease control institutes, and collaborative reference laboratories, and assemble diverse
technical elements such as disease surveillance methods, emergency operations centers, and
vaccine distribution systems.
Humanitarian biomedicine, in contrast, targets diseases that currently afflict the
poorer nations of the world, such as malaria, tuberculosis and HIV/ AIDS. Its problematic
is one of alleviating the suffering of individuals, regardless of national boundaries or social
groupings. Such intervention is seen as necessary where public health infrastructure at the
nation-state level is in poor condition or non-existent. Humanitarian biomedicine tends to
develop “apolitical” linkages – between non-governmental organizations, activists, scientific
researchers and local health workers. Its target of intervention is not a collectivity conceived
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as a national population but rather individual human lives. As a sociotechnical project, this
regime seeks to bring advanced diagnostic and pharmaceutical interventions to those in
need; this involves both providing access to existing medical technologies and spurring the
development of new medications addressed to “neglected diseases” – ie. diseases not
currently targeted by the pharmaceutical and biotechnology industries. Whereas global health
security develops prophylaxis against potential threats at home, humanitarian biomedicine
invests resources to mitigate present suffering in other places. Moreover, each regime
responds to a different conception of the problem to which global health efforts are a
response.2 Global health security responds to an ecological problem: new forms of circulation
have made it easier for emerging pathogens to spread rapidly across populations.
Humanitarian biomedicine responds to a technological problem: needy populations do not
have access to advanced biomedical interventions.
Each regime is “global” in the sense that it strives to transcend certain limitations
posed by the national governance of public health. Within each regime actors work to craft a
space of the global that will be a site of knowledge and intervention.3 However, the type of
ethical relationship implied by a project of global health depends upon the regime in which
the question is posed: the connection between health advocates and the afflicted (or
potentially afflicted) can be one of either moral obligation to the other or protection against
risk to the self. Global health is, in this sense, a contested ethical, political and technical zone
whose contours are still under construction.
Governing Pathogens
A recent case illustrates the tensions that can arise at the intersection of these two
regimes. In an opinion piece published in the Washington Post in August 2008, diplomat
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Richard Holbrooke and science journalist Laurie Garrett mounted a sharp attack on what
they called “viral sovereignty.” By this term, the authors referred to the “extremely
dangerous” idea that sovereign states could exercise ownership rights over samples of
viruses found in their territory. Specifically, Holbrooke and Garrett were incensed by the
Indonesian government’s refusal to share samples of H5N1 avian influenza with the World
Health Organization’s Global Influenza Surveillance Network (GISN). For over fifty years,
this network had collected samples of flu viruses from around the world and used these
samples to determine the composition of yearly flu vaccines. More recently, the network had
tracked the transformations of avian influenza viruses as a means of assessing the risk of a
deadly global pandemic.4 International health experts feared that the new strain of H5N1,
which had already proven highly virulent, would mutate to become easily transmissible
among humans – in which case a worldwide calamity could be at hand. GISN thus served as
a global “early warning system” enabling experts to track genetic changes in the virus that
could lead to a catastrophic disease event.
As the country where the most human cases of avian influenza had been reported,
Indonesia was a potential epicenter of such an outbreak. For this reason, the country’s
decision to withhold samples of the virus undermined GISN’s function as a global early
warning system. From Holbrooke and Garrett’s vantage, Indonesia’s action posed a
significant threat to global health. “In this age of globalization,” they wrote, “failure to make
viral samples open-source risks allowing the emergence of a new strain of influenza that
could go unnoticed until it is capable of exacting the sort of toll taken by the pandemic that
killed tens of millions in 1918.” According to Garrett and Holbrooke, Indonesia had not
only a moral but also a legal obligation to share its viruses with the World Health
Organization. They argued that the country’s action was a violation of the newly revised
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International Health Regulations (IHR), which held the status of an international treaty for
WHO member states.
The opinion piece suggested that the rational and beneficent technocracy of the
WHO was faced with anti-scientific demagoguery that threatened the world’s health.
Holbrooke and Garrett painted a picture of the Indonesian Health Minister, Siti Fadilah
Supari, as an irrational populist who sought to make domestic political gains through
unfounded attacks on the US and the international health community. Indonesia was
apparently withholding these virus samples based on the “dangerous folly” that these
materials should be protected through the same legal mechanism that the U.N. Food and
Agriculture Organization used to guarantee poor countries’ rights of ownership to
indigenous agricultural resources – the Convention on Biological Diversity. Further,
Holbrooke and Garrett rebuked Supari’s “outlandish claims” that the US government was
planning to use Indonesia’s H5N1 samples to design biological warfare agents - echoing US
Secretary of Defense Robert Gates’ reaction upon hearing this accusation during a visit to
Jakarta: “the nuttiest idea I’ve ever heard.”5
The controversy over influenza virus-sharing was, it turned out, somewhat more
complicated than Holbrooke and Garrett allowed. Beginning in late 2006, at Supari’s behest,
the Indonesian Health Ministry had stopped sharing isolates of H5N1 found in patients who
had died of avian influenza with the Global Influenza Surveillance Network. The source of
Supari’s ire was the discovery that an Australian pharmaceutical company had developed a
patented vaccine for avian flu using an Indonesian strain of the virus – a vaccine that would
not be affordable for most Indonesians in the event of a deadly pandemic. More generally,
given the limited number of vaccine doses that could be produced in time to manage such a
pandemic – estimates were in the 500 million range – experts acknowledged that developing
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countries would have little access to such a vaccine. In other words, while Indonesia had
been delivering virus samples to WHO as part of a collective early warning mechanism (ie.
GISN), they would not be beneficiaries of the biomedical response apparatus that had been
constructed to prepare for a deadly global outbreak. For the Indonesian health minister, this
situation indicated a dark “conspiracy between superpower nations and global
organizations.”
While less suspicious of US and WHO intentions than Supari, a number of Western
journalists and scientists were sympathetic to the Indonesian position – on the grounds of
equity in the global distribution of necessary medicines. A Time magazine article noted that
“they had a point; poor developing nations are often priced out of needed medicines, and
they’re likely to be last in line for vaccine during a pandemic.”6 An editorial in the Lancet
argued, “to ensure global health security, countries have to protect the wellbeing not only of
their own patients but also those of fellow nations.”7 Anxious to ensure the functioning of
its surveillance apparatus, WHO was willing to strike a bargain: at a World Health Assembly
meeting in 2007, members agreed to explore ways of helping poorer countries to build
vaccine production capacity. But the financial and technical details of how such a system
would function were opaque, and the issue remained unresolved. In October 2008, as
Indonesia continued to withhold the vast majority of its avian influenza samples from GISN,
Agence France-Presse reported that “Supari does appear to be vindicated by a flood of
patents being lodged on the samples of H5N1 that have made it out of Indonesia, with
companies in developed countries claiming ownership over viral DNA taken from sick
Indonesians.”8 The Australian drug company CSL acknowledged that it had used Indonesian
bird flu strains to develop a trial vaccine, but insisted that it had no obligation to compensate
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Indonesia or guarantee access to the vaccine. Unlike the data generated by GISN, vaccine
access was not “open-source.”
A good deal more could be said about the controversy over Indonesia’s refusal to
share its H5N1 samples, but I want to focus here on just one aspect of Holbrooke and
Garrett’s attack: their accusation that Indonesia was in violation of the revised International
Health Regulations (IHR). The IHR system, dating from the 1851 International Sanitary
Law, defines states’ mutual obligations in the event of an outbreak of a dangerous
communicable disease. Historically, its function has been to guarantee the continued flow of
global commodities in the event of such outbreaks, ensuring that countries do not take
overly restrictive measures in response to the threat of infection. The H5N1 virus sharing
controversy unfolded just after a major revision of these regulations. According to legal
scholar David Fidler, the 2005 IHR revision was “one of the most radical and far-reaching
changes in international law on public health since the beginning of international health cooperation in the mid-nineteenth century.”9
For my purposes here, the revised IHR are best understood as a significant element
in an emerging apparatus of global disease surveillance and response – what the World
Health Organization called “global public health security.” The IHR instituted a new set of
legal obligations for nation-states to accept global intervention in a world seen as under
threat from ominous pathogens circulating ever more rapidly. A key provision expanded the
list of the diseases that would be subject to international regulation and potential
intervention beyond the classic infections of the nineteenth century – cholera, yellow fever
and plague. Now any disease outbreak that could be classified as a “public health emergency
of international concern” – such as SARS, or an easily transmissible form of H5N1 – would
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be covered by the IHR regulations. International law experts saw the virus-sharing
controversy as an early test of how well the revised IHR would function.
According to the new regulations, IHR signatories were required to provide WHO
with “public health information about events that may constitute a PHEIC” [public health
emergency of international concern].10 In the case of the virus sharing controversy, the
central legal question was whether biological materials constituted such “public health
information.” Plausible arguments could be made on both sides. At the May 2007 meeting
of the World Health Assembly, WHO Director Margaret Chan claimed that “countries that
did not share avian influenza virus would fail the IHR.”11 The US delegation agreed: “All
nations have a responsibility under the revised IHRs to share data and virus samples on a
timely basis and without preconditions.”12 Thus, the US argued, “our view is that
withholding influenza viruses from GISN greatly threatens global public health and will
violate the legal obligations we have all agreed to undertake through our adherence to
IHRs.” However, the relevance of the revised IHR to the specific issue of virus sharing was
ambiguous: the new regulations explicitly referred only to a requirement to share public
health information, such as case reports and fatality rates, and the case could be made that
biological materials such as virus samples were distinct from such information.13
In any case, the Indonesian Health Ministry’s response came from outside of the
legal framework of IHR. Rather, Supari argued that the global virus sharing system was
ethically compromised, and in need of reform. “We want to change the global virus sharing
mechanism to be fair, transparent and equitable,” Supari said in an interview defending the
government’s decision to withhold the virus.14 “What we mean by fair is that any virus
sharing should be accompanied by benefits derived from the shared virus, and these benefits
should be coming from the vaccine producing countries.” Supari was speaking from within a
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different technopolitical problematic than that of the WHO’s framework of “global public
health security,” the strategy that the revised IHR was designed to serve. In speaking of
benefits-sharing, Supari was invoking a mechanism intended to encourage development –
the Convention on Biological Diversity – in order to ground a rhetoric of national
sovereignty that ran counter to the transnational authority of the WHO. But her attack on
the high price of patented vaccines also resonated with demands for equal access to lifesaving medicines coming out of the humanitarian global health movement.
A technical and political system designed to prepare for potentially catastrophic
disease outbreaks was facing a very different demand: a call for access to essential medicines
based on a vision of global equity (see figure 1). The potential for a deadly outbreak of avian
influenza had led to an encounter between two different ways of conceptualizing the
problem of global health – one that was taking place in the absence of an actual health
emergency. At stake was not only the issue of how best to respond to a global outbreak of
H5N1; but more broadly, how to define the political obligation to care for the population’s
health in a globalizing world in which the capacity of national public health authorities to
protect citizens’ well-being was increasingly in question.
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Figure 1: Regimes of Global Health
Global Health Security
Humanitarian Biomedicine
Type of threat
Emerging infectious diseases
that threaten wealthy
countries
Neglected diseases that afflict
poor countries
Source of pathogenicity
Social and ecological
transformations linked to
globalization
Failure of development; lack
of access to health care
Organizations and
actors
National and international
health agencies; technocrats
NGOs, philanthropies,
activists
Technopolitical
interventions
Global disease surveillance;
building response capacity;
rapidly develop biomedical
interventions to manage novel
pathogens
Provide access to essential
medicines; drug and vaccine
research and development for
diseases of the poor
Target of Intervention
National public health
infrastructures
Suffering individuals
Ethical stance
Self-protection
Common humanity
Assembling Global Health
Each of these regimes can be seen as a response to a crisis of existing, nation-state
based systems of public health. From the vantage of global health security, this crisis comes
from the recognition that existing national public health systems are inadequate to prepare
for the potentially catastrophic threat of emerging and reemerging infectious diseases. Such
diseases outstrip the capabilities of modern public health systems that were designed to
manage known diseases that occur with regularity in a national population. For humanitarian
biomedicine, in contrast, the crisis comes from the failure of development efforts to provide
adequate health infrastructure to lessen the burden of treatable, but still deadly maladies in
poor countries: it is a political and technical failure rather than the result of disease
emergence per se. For humanitarian biomedicine, especially in the context of “low capacity”
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states in which public health infrastructure has collapsed, human suffering demands urgent
and immediate response outside of the framework of state sovereignty.
Despite their differences, each of these regimes of global health has borrowed
certain aspects of earlier public health formations, adapting them for new uses in the postCold War era. Public health systems in Europe and North America were initially built in the
mid-to-late nineteenth century in response to social pathologies linked to industrialization in
urban centers.15 For these systems, the object of knowledge and intervention was the
population: its rates of death and disease, cycles of scarcity, and endemic levels of mortality.
Public health advocates uncovered patterns of disease incidence linked to living conditions
that could be reduced through technical interventions.16 Statistical knowledge, generated in
fields such as epidemiology and demography, made these collective regularities visible. This
form of public health sought to know and to manage such regularities, to decrease mortality
and increase longevity – to “optimize a state of life,” as Michel Foucault put it.17
For this early form of public health, the design of interventions required the analysis
of historical patterns of disease in a given population. For example, as historian George
Rosen has shown, nineteenth century British public health reformers carefully tracked the
incidence of disease according to differential social locations to make the argument that
“health was affected for better or worse by the state of the physical or social environment.”18
Such knowledge was cumulative and calculative. Reformers gathered and analyzed vital
statistics – rates of birth, death, and illness among various classes – in order to demonstrate
the economic rationality of disease prevention measures such as the provision of clean water
or the removal of waste from streets.19 If this initial mode of public health intervention
emphasized social conditions – sanitation, nutrition, the safety of factories – a next iteration
of public health narrowed its focus to the level of the pathogen. The rise of bacteriology in
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the late nineteenth century led to the systematic practice of mass vaccination against
infectious disease. But again, for these early forms of public health, making rational
interventions required statistical knowledge about the historical pattern of disease incidence
in a specific population.20
Cold War era international health efforts, as exemplified by the World Health
Organization after its founding in 1948, had two main currents: disease eradication and
primary health care.21 The major international disease eradication efforts were the WHO-led
malaria campaign beginning in 1955 (and abandoned by the early 1970s) and the more
successful smallpox eradication campaign, again led by WHO, and completed in 1977. Such
initiatives were international – rather than “global” – in that they required coordination
between WHO and national public health services. The other main current of Cold War era
international health, “primary health care,” articulated health as a basic human right linked to
social and economic development. The essential medicines movement, linked to this
approach, was a precursor to contemporary efforts to ensure access to biomedical
interventions. Again, this vision was international rather than global: a functioning nationstate apparatus was seen as central to the delivery of basic primary care and so state-based
development efforts were critical to the improvement of population health.
By the early 1990s the primary health care model linked to the developmental state
was in crisis. Funding dried out for primary health schemes in the context of the influence of
World Bank-led, privatizing reforms of national health systems. The WHO shifted its
energies toward vertically integrated public-private partnerships that focused on managing
specific diseases – such as HIV/ AIDS and TB – rather than on developing local health
infrastructures. As a group of public health historians has recently suggested, competition
between the World Health Organization and the World Bank over the field of primary care
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was one motivation for WHO’s move toward such public-private global health initiatives.22
The Gates Foundation also played a key early role in this shift, funding $1.7 billion worth of
projects from 1998 – 2000. Gates was then joined in this type of disease-focused initiative by
other donor-funded institutions, such as the UN Global Fund and the Clinton Global
Initiative.
Contemporary regimes of global health take up aspects of earlier public health
programs but adapt them to a different set of circumstances. Global health security seeks to
direct certain elements of existing national health systems toward its goal of early detection
and rapid containment of emerging infections. Since the focus of this regime is on potential
disease events, whose likelihood cannot be calculated using statistical methods, it develops
techniques of imaginative enactment that model the impact of an outbreak. Global health
security demands compliance from national governments in developing preparedness
measures against potential outbreaks that threaten global catastrophe. Like classical public
health, humanitarian biomedicine is concerned with actually existing diseases, but it
functions outside of a state apparatus; its object of concern is not the national population
but rather suffering individuals irrespective of national borders. If a major ethical imperative
for classical public health efforts was one of social solidarity, that of humanitarian
biomedicine is one of common humanity.
Humanitarian Biomedicine
By the term “humanitarian biomedicine,” I do not refer to a single, clearly articulated
framework or tightly linked set of institutions; rather I mean to indicate a congeries of actors
and organizations with diverse histories, missions, and technical approaches. They share
what Peter Redfield calls “a secular commitment to the value of human life” – one that is
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practiced through medical intervention.23 This ethical commitment underlies a sense of
urgency to provide care to suffering victims of violence, disease and political instability. The
structure of intervention is one in which medical organizations and philanthropies from
advanced industrial countries engage in focused projects of saving lives in the developing
world – and these efforts explicitly seek to avoid political involvement.24
There is an increasing body of anthropological research on the problems inherent to
this type of intervention.25 My goal here will not be to provide a thorough review of this
work, but rather to point briefly to some of the salient points of juxtaposition with global
health security. We can take as exemplary instances of humanitarian biomedicine two
prominent – though quite distinctive – organizations: Medecins sans frontiers (MSF) and the Bill
and Melinda Gates Foundation. In her 1995 analysis of MSF, Renée Fox writes that the
organization’s efforts are premised on the “conviction that the provision of medical care,
service, and relief is a humane form of moral action” – that medical practice has the capacity
to heal the body politics as well as the human body.26 MSF has an actively “global” sense of
its mission, challenging the ‘sacred principle’ of the sovereignty of the state and claiming a
new world order based on Universal Declaration of Human Rights. Though articulated in an
idiom of economic rationality, the Gates Foundation’s rationale for intervention is similarly
based on a vision of common humanity: as Melinda Gates said in unveiling her foundation’s
new malaria eradication program, “the first reason to work to eradicate malaria is an ethical
reason – the simple cost. Every life has equal worth. Sickness and death in Africa are just as
awful as sickness and death in America.”27 It is worth contrasting this ethical rationale for
malaria eradication – one grounded in common humanity, ostensibly outside of politics –
with the developmentalist agenda at the heart of Cold War international health efforts, in
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which improving the health of a given population was inextricably tied to economic and
political modernization.28
The primary health care movement’s call for a “right to health for all” was carried
into humanitarian biomedicine, but this right was no longer to be concretized by national
governments, which were now seen as beset with corruption, incapable of reliably enacting
programs. Thus humanitarian biomedical initiatives to combat specific diseases such as
AIDS in the developing world expressly detach aid from existing national health agencies,
seeking to “govern through the non-governmental,” as Manjari Mahajan puts it in her
analysis of AIDS programs in India funded by Western donors such as the Gates
Foundation. “That which was explicitly ‘non-governmental’,” she notes, “was recruited to
provide public health services that had traditionally been in the ambit of the government.”29
In turn, in order to govern global health from outside of the state, the knowledge practices
that guide intervention, such as epidemiological modeling, must be transposable from local
contexts – a characteristic that, as we will see, also structures the governance of global health
security.
Given the desire to avoid political entanglement and to operate across multiple
settings, humanitarian biomedicine tends to emphasize technical interventions such as drugs,
vaccines or bed nets rather than primary health infrastructure. A prominent example is work
by activist organizations as well as philanthropies and multilateral agencies to increase access
to anti-retroviral therapies,30 as well as coordinated work to develop new treatments and
protocols for treating “neglected” diseases such as malaria and tuberculosis in resource poor
settings.31 In some cases, humanitarian biomedicine has moved toward ambitious
biotechnical projects, as in the Gates Foundation’s funding of basic research in the genomics
of drug resistant TB and malaria. Meanwhile, critics have argued that such an emphasis on
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technical approaches ignores the more fundamental sources of suffering in developing
countries – the living conditions of the world’s poor. Thus Anne-Emanuelle Birn writes, “in
calling on the world’s researchers to develop innovative solutions targeted to ‘the most
critical scientific challenges in global health,’ the Gates Foundation has turned to a narrowly
conceived understanding of health as a product of technical interventions divorced from
economic, social, and political contexts.”32 In a similar vein, Redfield describes the limits of
MSF’s campaign to provide chronic care for AIDS patients in Uganda: “In identifying
structural deficits in the global supply of pharmaceuticals, MSF has recognized poverty as a
condition for which it offers no cure.”33
Global Health Security
Global health security responds to very different problematic, as we can see by
looking at a 2007 report from the World Health Organization which articulated its objects
and aims.34 The report, entitled “A Safer Future: Global Public Health Security in the 21st
Century,” began by noting the success of traditional public health measures during the
twentieth century in dealing with devastating infectious diseases such as cholera and
smallpox. But in recent decades, it continued, there had been an alarming shift in the
“delicate balance between humans and microbes.”35 A series of factors – including
demographic changes, economic development, global travel and commerce, and conflict –
had “heightened the risk of disease outbreaks,” ranging from new infectious diseases such as
HIV/AIDS and drug-resistant tuberculosis to food-borne pathogens and bioterrorist
attacks.36
The WHO report proposed a strategic framework for responding to this new
landscape of threats, which it called “global public health security.” The framework
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emphasized an arena of global health that was distinct from the predominantly national
organization of traditional public health. “In the globalized world of the 21st century,” the
report began, simply stopping disease at national borders was not adequate. Nor was it
sufficient to respond to diseases after they had become established in a population. Rather, it
was necessary to prepare for unknown outbreaks in advance, something that could be
achieved only “if there is immediate alert and response to disease outbreaks and other
incidents that could spark epidemics or spread globally and if there are national systems in
place for detection and response should such events occur across international borders.”37
The strategic framework of “global health security” was a culmination of two
decades of increasing concern over the problematic of “emerging infectious disease.” This
problematic was initially raised by a group of US-based infectious disease experts in the late
1980s and early 1990s.38 In 1989, Nobel-prize winning molecular biologist Joshua Lederberg
and virologist Stephen Morse hosted a conference on the topic, which led to the landmark
volume, Emerging Viruses.39 Lederberg and Morse shared an ecological vision of disease
emergence as the result of environmental transformation combined with increased global
circulation.40 Participants in the conference warned of a dangerous intersection. On the one
hand, there were a number of new disease threats, including novel viruses such as AIDS and
Ebola as well as drug resistant strains of diseases such as tuberculosis and malaria. On the
other hand, public health systems worldwide had begun to decay, beginning in the late 1960s
with the assumption that infectious disease had been conquered. Moreover, the appearance
of new infectious diseases could be expected to continue, due to a number of global
processes, such as increased travel, urbanization, civil wars and refugee crises, and
environmental destruction. For these experts, the AIDS crisis heralded a dangerous future in
which more deadly diseases were likely to emerge.
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Over the ensuing years, alarm about emerging disease threats came from various
quarters, including scientific reports by prominent organizations such as the Institute of
Medicine, the reporting of journalists such as Laurie Garrett, and the dire scenarios of
writers such as Richard Preston.41 For many health experts, the emerging disease threat –
particularly when combined with weakening national public health systems – marked a
troublesome reversal in the history of public health. At just the moment when it seemed that
infectious disease seemed was about to be conquered, and that the critical health problems
of the industrialized world now centered on chronic disease, these experts warned, we were
witnessing a “return of the microbe.”
It is worth emphasizing the generative character of the category of “emerging
infectious disease.” The category made it possible to bring AIDS into relation with a range
of other diseases, including viral hemorrhagic fevers, West Nile virus, dengue, and drug
resistant strains of malaria and tuberculosis. It also pointed toward the imperative to develop
means of anticipatory response that could deal with a disparate set of disease threats.
Initiatives that would later come to be associated with global health security were first
proposed in response to this perceived need.
Practices of disease eradication that had been honed as part of Cold War
international health were incorporated into proposed solutions to the problem of emerging
disease. One contributor to Emerging Viruses was epidemiologist D.A. Henderson, who had
implemented techniques of disease surveillance in the 1960s and 1970s as director of the
WHO Smallpox Eradication Program. For Henderson, the task was not one of prevention
but of vigilant monitoring. He argued that novel pathogen emergence was inevitable – that
“mutation and change are facts of nature, that the world is increasingly interdependent, and
that human health and survival will be challenged, ad infinitum, by new and mutant
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microbes, with unpredictable pathophysiological manifestations.”42 As a result, “we are
uncertain as to what we should keep under surveillance, or even what we should look for.”
What we need, he continued, is a system that can detect novelty: in the case of AIDS, such a
detection system could have provided early warning of the new virus and made it possible to
put in place measures to limit its spread. Henderson proposed a system of global disease
surveillance units to be run by CDC, and located in peri-urban areas in major cities in the
tropics, which could provide a “window on events in surrounding areas.” Thus, tools of
disease eradication that had been developed as part of Cold War international health –
surveillance, outbreak investigation, and containment – were brought to bear to address the
newly articulated problem of emerging infectious disease.
Over the course of the 1990s, the emerging disease problematic was integrated into
US national security discussions. Security experts began to focus on bioterrorism as one of a
number of “asymmetric threats” the nation faced in the wake of the Cold War,
hypothesizing an association between rogue states, global terrorist organizations and the
proliferation of weapons of mass destruction.43 Reports during the 1990s about Soviet and
Iraqi bioweapons programs, along with the Aum Shinrikyo subway attack in 1995, lent
credibility to calls for biodefense measures focused on the threat of bioterrorism. Early
advocates of such efforts, including infectious disease experts such as Henderson and
national security officials such as Richard Clarke, argued that adequate preparation for a
biological attack would require a massive infusion of resources into both biomedical research
and public health response capacity.44 More broadly, they maintained, it would be necessary
to incorporate the agencies and institutions of the life sciences and public health into the
national security establishment. In the 1990s, Henderson and others connected the interest
in emerging diseases among international health specialists with national security officials’
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concern about the rise of bioterrorism, suggesting that a global disease surveillance network
could serve to address both problems.
Epidemic Intelligence
Henderson’s model of disease surveillance came out of his background at the
Epidemic Intelligence Service (EIS) based at the Centers for Disease Control (CDC).45 The
approach, developed in the 1950s, was one of “continued watchfulness over the distribution
and trends of incidence through systematic consolidation and evaluation of morbidity and
mortality data and other relevant data,” as his mentor Alexander Langmuir put it.46
Henderson used this method in tracking the global incidence of smallpox as director of the
WHO eradication program. His proposed global network of surveillance centers and
reference laboratories extended this approach to as yet unknown diseases, providing early
warning for response to outbreaks of any kind – whether natural or man-made.47
The “epidemic intelligence” approach to emerging infections was institutionalized at
a global scale over the course of the 1990s as experts from CDC imported the methods of
EIS into the World Health Organization. The career of epidemiologist David Heymann is
instructive. Heymann began his career in EIS, and in the 1970s worked with CDC on disease
outbreak containment in Africa and with WHO on the smallpox eradication program.48 In
the early years of the AIDS pandemic, he helped establish a WHO office to track the
epidemiology of the disease in developing countries. He then returned to Africa in 1996 to
lead the response to a widely publicized Ebola outbreak in Congo. After this he was asked
by the Director of WHO to set up a program in emerging diseases. “At this time there was
an imbalance in participation internationally in the control of emerging and re-emerging
infectious diseases,” he later recalled, “the burden was falling mainly on the USA.”49 At
20
WHO, Heymann set up a global funding mechanism that broadened the agency’s emerging
disease surveillance and response capacities along the CDC model.
In the wake of the Ebola outbreak, as well as catastrophic outbreaks of cholera in
Latin America and plague in India in the early 1990s, Heymann later reflected, a “need was
identified” for stronger international coordination of response.50 A major problem for
outbreak investigators was that national governments often did not want to report the
incidence of a disease that could harm tourism and international trade. The case of the
plague outbreak in Surat in 1994, in which Indian officials suppressed international reporting
of the event, was an oft-cited example of the difficulty of forcing countries to publicly report
epidemics.51
Advocates of the emerging disease problematic suggested revision of the existing
International Health Regulations as one potential solution to the problem of national
compliance. In the context of emerging diseases, the existing IHR had proven ineffectual in
forcing disease notification for at least two reasons. For one, the limited list of reportable
conditions – cholera, plague, and yellow fever – was of little relevance for the expansive
category of emerging infections; second, there was no way to require countries to comply
with IHR reporting requirements. Although, as Heymann put it, “in our emerging diseases
program our idea was to change the culture so that countries could see the advantage of
reporting,” a practical means of enforcing compliance was needed. The revision of IHR
became a vehicle for outbreak investigators to finally construct the functioning global
surveillance system that had been proposed by Henderson and others. Health authorities
proposed three key innovations to IHR that would make it possible for WHO to manage a
range of potential disease emergencies.
21
The first innovation – mentioned above in the context of the Indonesian virussharing controversy – responded to the problem of the narrow range of conditions to which
the existing IHR could be applied. Through the invention of the concept of the “public
health emergency of international concern” (PHEIC), the revised regulations vastly
expanded the kinds of events to which the regulations might apply. Naturally occurring
infectious diseases such as influenza and Ebola, intentional releases of deadly pathogens
such as smallpox, or environmental catastrophes such as those that occurred at Bhopal in
1984 and Chernobyl in 1986 could, according to the new regulations, provoke the
declaration of a PHEIC. The IHR “decision instrument” was an important tool for guiding
states in determining what would constitute a public health emergency that required the
notification of WHO (see figure 2). However, as we saw in the Indonesian H5N1 case, the
pathway in the decision instrument defined as “any event of international public health
concern” left considerable room for interpretation of the scope of the regulations.
22
Figure 2: IHR Decision Instrument
23
The second major innovation in the revised IHR responded to the problem of the
concentration of epidemiological knowledge in national public health agencies. The new
regulations expanded the potential sources of reports of outbreaks: whereas the prior IHR
had restricted actionable reporting to national governments, the revised IHR allowed WHO
to recognize reports from non-state sources such as digital and print media. In this way, state
parties’ unwillingness to report outbreaks would not impede the functioning of the global
monitoring system. The premise was that, given WHO’s official recognition of non-state
monitors, reports of outbreaks could no longer be suppressed and so it would be in states’
interest to allow international investigators into the country as soon as possible in order to
undertake disease mitigation measures and to assure the public that responsible intervention
was under way. The creation during the 1990s of internet-based reporting systems such as
ProMED in the US and GPHIN in Canada that scoured international media for stories
about possible outbreaks was critical here: global public health surveillance no longer relied
exclusively on state-based epidemiological methods such as the official case report.52 In
1997, WHO established GOARN (Global Outbreak Alert and Response Network), a system
linking individual surveillance and response networks. The potential for the rapid circulation
of infectious disease information undermined national governments’ traditional control of
public health knowledge, making a “global” form of disease surveillance possible.
The third major innovation of the revised IHR addressed the problem of countries’
ability to monitor outbreaks. It required that states build national capacity for infectious
disease surveillance and response. The construction of these “national public health
institutes” on the model of CDC would make possible a distributed global network that
relied on the functioning of nodes in each country. Here again, it is worth noting the
contrast with the developmentalist model of health infrastructure. IHR’s reliance on national
24
health systems did not necessarily imply strengthening governmental capacity to manage
existing disease; rather, it sought to direct the development of outbreak detection systems
according to the needs of global disease surveillance. As one document put it: “It is
proposed that the revised IHR define the capacities that a national disease surveillance
system will require in order for such emergencies to be detected, evaluated and responded to
in a timely manner.”53 WHO gave countries until 2016 to fulfill this obligation. However, it
was unclear where the resources would come from to make it possible to implement systems
for detecting rare diseases in poor countries that already had trouble managing the most
common ones.
Rolling out the system: SARS
While the revised IHR were not officially approved by the World Health Assembly
until 2005, the SARS outbreak of early 2003 gave Heymann and his colleagues in WHO’s
Emerging Infections branch an early opportunity to roll out elements of the agency’s new
global surveillance and response system. As an outbreak of an unknown and unexpected, but
potentially catastrophic viral disease, SARS fit well into the existing category of “emerging
infections.”54 The Chinese government’s initial recalcitrance to fully report the outbreak led
WHO to rely on its new capacity to use non-state sources of information: SARS was the first
time the GOARN network identified and publicized a rapidly spreading epidemic. As
opposed to recalcitrant governments, Heymann said, international scientists “are really
willing to share information for the better public good.”55 GOARN made it possible to
electronically link leading laboratory scientists, clinicians and epidemiologists around the
world in a “virtual network” that rapidly generated and circulated knowledge about SARS.
WHO tracked the spread of the illness closely and issued a series of recommendations on
25
international travel restrictions. According to Heymann, who led the WHO response, this
rapid reaction was key to the containment of the epidemic by July 2003 – though he also
acknowledged the good fortune that SARS had turned out not to be easily transmissible.
The lesson Heymann drew from SARS was that, in a closely interconnected and
interdependent world, “inadequate surveillance and response capacity in a single country can
endanger the public health security of national populations and in the rest of the world.”56
This was the broad premise underlying the regime of global health security. Processes of
globalization – including migration, ecological transformations, and massive international
travel – had led to new disease threats – threats that transcended national borders and
therefore could not be ignored by wealthy countries. Only a global system of rapidly shared
epidemiological information could provide adequate warning in order to mitigate such risks.
National sovereignty must accede to the demands of global health security. This lesson was
then applied to the next potential disease emergency, avian influenza. As Holbrooke and
Garrett argued, in calling for Indonesia to comply with WHO’s influenza virus-sharing
network, SARS had proven that “globally shared health risk demands absolute global
transparency.”
Applying the New Regulations: XDR-TB
The first invocation of the revised International Health Regulations came in an
unexpected context: not the outbreak of a deadly new pathogen in a country of the
developing world, but rather the diagnosis of an American air traveler with a dangerous
strain of tuberculosis.57 In the Spring of 2007 an Atlanta lawyer named Andrew Speaker was
diagnosed with multi-drug resistant tuberculosis just before leaving on his honeymoon to
Europe. Speaker ignored the CDC’s recommendation not to travel, and flew to Europe with
26
his wife. The CDC then informed him by phone that a follow up test had indicated that he
had extremely drug resistant TB (XDR-TB), a rare form of the disease that is very difficult to
treat. The CDC told Speaker that he would either have to stay in Europe, quarantined in an
Italian hospital, or pay his own way back to the US on a private, medically secured jet.
Instead, Speaker bought a commercial plane ticket to Montreal on the Internet and was able
to drive into the US via the Canadian border, even though he had been placed on a
Department of Homeland Security watch list. The event briefly caused an international
panic, as health officials worried that Speaker had exposed fellow passengers to the pathogen
during the long trans-Atlantic flight.
From the vantage of global health security, the Speaker case was a test of the new
health preparedness system. As a New York Times reporter wrote, “the bizarre case calls
into question preparations to deal with medical crises like influenza pandemics and even
bioterror attacks.”58 Similarly, a Los Angeles Times editorial warned: “One day, a plane landing
at LAX could carry a passenger infected with XXDR, a bioterror agent, Ebola or an
emerging virus. Will we be ready?”59 The Congressional Committee on Homeland Security
Issued a report on the Speaker incident that linked XDR-TB to the broad problematic of
emerging infectious disease, whose solution would require the integration of public health
and security:
The twin specters of diseases that are increasingly resistant or completely without
current treatments and antimicrobials, and the ability of diseases to spread more
quickly than ever before due to rapid transit and other enablers, place public health
concerns squarely on the homeland, national, and transnational security agendas.
How we address these gaps now will serve as a direct predictor of how well we will
handle future events, especially those involving emerging, reemerging, and pandemic
infectious disease.60
27
But the Speaker case was far from representative of the global problem of drug
resistant TB. In fact the disease is one of the central objects of attention for humanitarian
biomedicine.61 For advocates of humanitarian biomedicine, the case was useful insofar as it
drew attention to an under-reported issue: the increasing incidence of multi- and extremely
drug resistant TB in parts of the world with poorly functioning public health systems, such
as South Africa and the former Soviet bloc. As one humanitarian activist urged: “We need to
wake up and pay attention to what's happening with TB in other parts of the world. We need
to start treating XDR-TB where it is, not just respond to one case of one American who will
get the finest treatment.”62 For humanitarian biomedicine, the growing epidemic of drugresistant TB pointed to the failures of public health systems to adequately manage a
treatable, existing condition among the world’s poor.63
Thus, if the specter of an airplane passenger with XDR-TB was seen a practice run
for a future bioterrorist attack, the questions – and answers – generated by the incident were
quite different than if the passenger were seen as a sign of an already existing health
emergency, but one taking place outside of the networks and nodes of our own health and
communications systems. The same disease could look quite different, and provoke quite
different responses, depending on whether it was taken up within regime of global health
security or one of humanitarian biomedicine.
Conclusion
Whether the revised IHR would live up to its billing as a radical transformation of
international public health in the direction of providing security against novel pathogens
would depend at least in part on its capacity to force sovereign states to comply with the
requirements of global health surveillance. The issue of intellectual property rights in the
28
case of Indonesian flu viruses indicated that an alternative regime of global health – one
focused on the problem of access to essential medicines in treating existing diseases – could
well complicate such efforts. Global health security did not address the major existing
infectious disease problems of the developing world – which were linked to poverty and the
lack of resources to devote to basic health infrastructure. As Fidler put it, “the strategy of
global health security is essentially a defensive, reactive strategy because it seeks to ensure
that States are prepared to detect and respond to public health threats and emergencies of
international concern… The new IHR are rules for global triage rather than global disease
prevention.”64
The program of global health security was limited; it did not have any means to
address, for example, the HIV/AIDS pandemic – and so did not attract the interest of
global health advocates focused on the existing health crises. It contained no provisions
regarding medication access, prevention programs, or vaccine research and development for
neglected diseases.65 As critic Philip Calain wrote, describing WHO-led projects such as
GOARN, “There is no escaping from the conclusion that the harvest of outbreak
intelligence overseas is essentially geared to benefit wealthy nations.”66 Humanitarian
biomedicine thus offered potential resources for the critique of what was left out of global
health security. Nonetheless, each regime functioned relatively coherently on its own –
leading to the question of whether, in fact, the two regimes might best be understood as
complementary rather than inherently contradictory facets of contemporary global health
governance. If so, humanitarian biomedicine could be seen as offering a philanthropic
palliative to nation-states lacking public health infrastructure in exchange for the right of
international health organizations to monitor their populations for outbreaks that might
threaten wealthy nations.
29
Epilogue: H1N1
The threat of the appearance of a virulent, easily transmissible strain of H5N1 led to
an array of pandemic preparedness measures, including contractual arrangements between
national governments and pharmaceutical companies to secure potentially scarce stocks of
anti-viral medication and flu vaccine in the event of a pandemic. In the Spring 2009, a
different type of flu – H1N1 – appeared in North America and began to spread to other
sites of disease surveillance. Under the International Health Regulations, H1N1 was named a
“public health emergency of international concern” on April 25, and on June 11, WHO
declared a phase 6 pandemic as the H1N1 virus spread globally. With this declaration,
national and international public health agencies were officially put on emergency footing,
and national pandemic preparedness plans were put into action. It was not that there were
already vast numbers of casualties from H1N1, but rather that one could envision a scenario
in which such casualties would take place. The task of health officials was to forestall the
unfolding of that scenario.
European and North American governments spent billions of dollars to procure
vaccine and implement mass immunization campaigns in anticipation of the fall flu season.
There was little effort to ensure that vaccine would be available in poor countries. “It’s
another example of the gap between the north and south,” said Michel Kazatchkine, the
executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. “In the
north, vaccines are being stockpiled, antiviral drugs are being stockpiled, all with the risk that
these things will not be effective. In the south, there are neither diagnostics nor treatment.”67
However, in the following year, the critique of pandemic preparedness measures took a
different turn.
30
As of early 2010, in Europe and in North America, the appropriateness of the
massive public health preparedness efforts that had been undertaken in anticipation of
H1N1 began to come under scrutiny. The United States had spent $1.6 billion on 229
million doses of vaccine in what the Washington Post called “the most ambitious
immunization campaign in U.S. history,” but had used less than half of the vaccine that it
had ordered.68 And European countries had for the most part used far less of their available
vaccine stocks.
Marc Gentilini, the former President of the French Red Cross, criticized the French
government for its “extravagant” spending on the H1N1 vaccination campaign. While
France had spent hundreds of millions of Euros on H1N1 vaccine purchases from major
pharmaceutical companies, less than ten percent of its population had been vaccinated as of
January 2010, and the country sought to unload its excess vaccine supplies. “Preparing for
the worst wasn’t necessarily preparing correctly,” said Gentilini.69 In turn, President Nicolas
Sarkozy defended himself against accusations that the French government had badly overreacted to the threat of pandemic H1N1.70 “I will always prefer to be too prudent when it
comes to people’s health than not enough.”
Critics argued that billions of dollars spent on vaccines had been squandered in
trying to manage a disease that turned out to be less dangerous than seasonal flu. In
testimony before the Health Committee of the European Council, German epidemiologist
Ulrich Keil accused health agencies of misallocating resources that could have been devoted
to diseases that currently kill millions per year: “Governments and public health services are
paying only lip service to the prevention of these great killers and are instead wasting huge
amounts of money by investing in pandemic scenarios whose evidence base is weak.” Others
suggested that collective hysteria, or dark capitalist conspiracy, rather than actual evidence of
31
risk led to the intensive global response to H1N1. The Chair of the European Council’s
Health Committee, Wolfgang Wodarg, argued that the pandemic declaration and response
was “one of the greatest medical scandals of the century,” decrying pharmaceutical industry
influence on public health decision-making and a “conflict of interest” within the World
Health Organization.
However, such claims failed to see the internal logic of the agency’s response to
H1N1. Once the H1N1 pandemic proved mild, officials were open to accusations that they
had acted irrationally at best. However, it was not a question of acting more or less
rationally. Rather, the question was: according to which form of rationality would one act? The
development, over the prior two decades, of a system of global health security oriented
toward intervention in advance of potential disease catastrophe had made the decision to enact
emergency measures not just thinkable, but arguably, inevitable.
A widely cited recent article notes: “Although frequently referenced, global health is rarely defined. When it is,
the definition varies greatly and is often little more than a rephrasing of a common definition of public health
or a politically correct updating of international health.” Jeffrey Koplan, et al., “Toward a Common Definition
of Global Health,” The Lancet 373 (June 6, 2009): 1993 – 1995.
1
See Paul Rabinow’s call for the study of contemporary problematizations, in Anthropos Today: Reflections on
Modern Equipment (Princeton, 2003).
3 Stephen J. Collier and Aihwa Ong, “Global Assemblages, Anthropological Problems,” in Global Assemblages:
Ethics, Technology and Politics as Anthropological Problems, ed. Aihwa Ong and Stephen J. Collier (New York:
Blackwell, 2004).
2
The Director of WHO’s communicable diseases cluster leader, David Heymann, described the network as
follows: GISN “identifies and tracks antigenic drift and shifts of influenza viruses to guide the annual
composition of vaccines, and provides an early alert to variants that might signal the start of a pandemic.”
Heymann, “The International Response to the Outbreak of SARS in 2003,” Philosophical Transactions of the Royal
Society of London B, 359, (2004): 1127 – 1129. For an anthropological critique, see Carlo Caduff, “Anticipations
of Biosecurity,” in Biosecurity Interventions: Global Health and Security in Question, ed. Andrew Lakoff and Stephen J.
Collier (New York: Columbia University Press, 2008).
4
“Indonesia’s Bird Flu Warrior Takes on the World,” Agence-France Press, Oct. 12, 2008.
Bryan Walsh, “Indonesia’s Bird Flu Showdown,” Time, May 10, 2007.
7 Editorial: “International Health Regulations: The Challenges Ahead,” The Lancet 369, (May 26, 2007): 1763.
8 “Indonesia’s Bird Flu Warrior Takes on the World, Agence-France Press, Oct. 12, 2008.
9 Fidler (2005), 326.
5
6
10
Citation in David P. Fidler, “Influenza Virus samples, International law, and
32
Global Health Diplomacy.” Emerging Infectious Diseases, 14, 1 (Jan 2008): 88 - 94.
11 Fidler, “Influenza Virus Samples.”
12 Fidler “Influenza Virus Samples.”
13 Fidler “Influenza Virus Samples.”
“Indonesia’s Bird Flu Warrior Takes on the World,” Agence-France Presse, October 12, 2008.
Elizabeth Fee and Dorothy Porter, “Public health, preventive medicine and professionalization: England and
America in the nineteenth century,” in Andrew Wear, ed., Medicine in Society: Historical Essays (Cambridge:
Cambridge University Press, 1992).
16 As Foucault noted, public health experts found “phenomena that are aleatory and unpredictable when taken
in themselves or individually, but which, at the collective level, display constants that are easy, or at least
possible, to establish.” Michel Foucault,“Society Must Be Defended”: Lectures at the College de France, 1975-1976 (New
York: Pantheon, 2003): 243.
14
15
ibid.
George Rosen, A History of Public Health (Baltimore: Johns Hopkins University Press, 1993): 185. For the
French case, see William Coleman, Death is a Social Disease: Public Health and Political Economy in Early Industrial
France (Madison: University of Wisconsin Press, 1982).
19 Thus, as Chadwick’s famous 1842 Inquiry into living conditions among the working classes argued, “the
expenditures necessary to the adoption and maintenance of measures of prevention would ultimately amount
to less than the cost of disease now constantly expanded.” Cit. in Rosen, op. cit., 187. Ian Hacking looks to this
period to find the moment when a “laws of sickness” were discovered, in part through the use of benefit
societies’ actuarial tables. Hacking, The Taming of Chance (Cambridge: Cambridge University Press, 1990).
20 For example, as Rosen notes, in designing New York City’s vaccination campaign against diphtheria among
schoolchildren in the 1920s, it was “necessary to know the natural history of diphtheria within the community:
How many children of different ages had already acquired immunity, how many were well carriers, and what
children were highly susceptible?” Rosen, op. cit., 312.
21 While I am focusing here on two major strands of Cold War international health, there is a complex history
of pre-WWII international health efforts ranging from the Rockefeller Foundation to the League of Nations
that historians of public health have recently begun to unravel. See, for example, Alison Bashford, “Global
Biopolitics and the History of World Health,” in History of the Human Sciences 19, 1 (2006): 67 – 88.
17
18
Theodore M. Brown, Marcos Cueto, and Elizabeth Fee. 2006, “The World Health Organization and the
Transition from ‘International’ to ‘Global’ Health,” American Journal of Public Health 96:1 (January 2006): 62 - 72.
23 Peter Redfield, “Doctors Without Borders and the Moral Economy of Pharmaceuticals.” In Alice Bullard,
ed., Human Rights in Crisis (Aldershot, UK: Ashgate Press, 2008): 132.
22
Didier Fassin emphasizes the paradoxes involved in the effort by Medecins sans frontieres to stage what he calls
a “politics of life” that deals with passive victims rather than active citizens: “humanitarian testimony
establishes two forms of humanity and two sorts of life in the public space: there are those who can tell stories
and those whose stories can be told only by others.” Fassin, “Humanitarianism as a Politics of Life,” Public
Culture 19, 3 (2007): 518.
24
See Fassin, “Humanitarianism as a Politics of Life”; Miriam Ticktin, “Where Ethics and Politics Meet: The
Violence of Humanitarianism in France,” American Ethnologist 33, 1 (Feb. 2006): 33 - 49; and Peter Redfield, "A
Less Modest Witness: Collective Advocacy and Motivated Truth in a Medical Humanitarian Movement"
American Ethnologist 33, 1 (Feb. 2006), 3 - 26.
26 Renée Fox, “Medical Humanitarianism and Human Rights: Reflections on Doctors Without Borders and
Doctors of the World,” Social Science and Medicine 41, 12: 1607 – 1616.
25
Melinda Gates, “Malaria Forum Keynote Address,” October 17, 2007. Text available at:
http://www.gatesfoundation.org/speeches-commentary/Pages/melinda-french-gates-2007-malaria-forum.aspx
(accessed 2/1/2010).
28 For the history of modernization theory and its political context, see Nils Gilman, Mandarins of the Future:
Modernization Theory in Cold War America (Baltimore: Johns Hopkins University Press, 2003).
27
33
Manjari Mahajan, “Designing Epidemics: models, policy-making, and global foreknowledge in India’s AIDS
epidemic,” Science and Public Policy 35, 8 (October 2008): 587.
30 Vinh-Kim Nguyen, “Antiretroviral Globalism, Biopolitics, and Therapeutic Citizenship,” in Global
Assemblages: Ethics, Technology and Politics as Anthropological Problems, ed. Aihwa Ong and Stephen J. Collier (New
York: Blackwell, 2004). Brazil’s efforts to increase ARV access serves as a model for many biomedical
humanitarians. For a critique, see Joao Biehl, “Pharmaceutical Governance,” In Global Pharmaceuticals: Ethics,
Markets, Practices, ed. Adriana Petryna, Andrew Lakoff, and Arthur Kleinman (Durham, N.C.: Duke University
Press, 2006).
31 Erin Koch, “Disease as a Security Threat: Critical Reflections on the Global TB Emergency,” in Biosecurity
Interventions: Global Health and Security in Question, ed. Andrew Lakoff and Stephen Collier (New York: Columbia
University Press, 2008).
29
Anne-Emanuelle Birn, “Gates’ grandest challenge: transcending technology as public health ideology,” The
Lancet 366, 9484 (2005): 514 – 519.
33 Peter Redfield, “Doctors Without Borders and the Moral Economy of Pharmaceuticals,” in Alice Bullard,
ed., Human Rights in Crisis (Vermont: Ashgate, 2008): 140.
32
This section draws on portions of Stephen J. Collier and Andrew Lakoff, “The Problem of Securing Health,”
Biosecurity Interventions: Global Health and Security in Question, ed. Andrew Lakoff and Stephen J. Collier (New York:
Columbia University Press, 2008).
34
World Health Organization, The World Health Report 2007: A Safer Future. Global Public Health Security in the 21st
Century (Geneva: WHO, 2007).
35
Charles Rosenberg has contrasted this new form of “civilizational risk” with those that sparked early public
health efforts, noting that anxieties about the risk of modern ways of life are here explained not in terms of the
city as a pathogenic environment, but in terms of evolutionary and global ecological realities. Rosenberg,
“Pathologies of Progress: the Idea of Civilization as Risk,” Bulletin of the History of Medicine 72, 4 (1998): 714 –
730.
37 World Health Organization, op. cit.
36
Nicholas King has analyzed the rise of the emerging disease framework in detail. See King, “Security,
Disease, Commerce: Ideologies of Post-Colonial Global Health,” Social Studies of Science 32, 5/6 (2002): 763 789.
38
39
Stephen S. Morse, ed. Emerging Viruses (New York: Oxford University Press, 1993).
Warwick Anderson describes this vision as follows: “Evolutionary processes operating on a global scale were
responsible for the emergence of ‘new’ diseases. As environments changed, as urbanization, deforestation, and
human mobility increased, so, too, did disease patterns alter, with natural selection promoting the proliferation
of microbes in new niches.” Warwick Anderson, “Natural Histories of Infectious Disease: Ecological Vision in
Twentieth Century Bioscience,” Osiris 19 (2004): 39 – 61.
40
Institute of Medicine, Emerging Infections: Microbial Threats to Health in the United States (Washington, D.C.,
National Academy Press, 1992); Laurie Garrett, The Coming Plague: Newly Emerging Diseases in a World out of
Balance (New York: Farrar, Straus and Giroux, 1994); Richard Preston, The Cobra Event (New York: Ballantine,
1998).
41
D. H. Henderson, “Surveillance Systems and Intergovernmental Cooperation,” in Stephen S., Morse, ed.
Emerging Viruses (New York: Oxford University Press, 1993).
42
Susan Wright, “Terrorists and Biological Weapons,” Politics and the Life Sciences 25, 1 (2006): 57 – 115.
As Susan Wright (ibid.) argues, the very use of the term “weapons of mass destruction” to link nuclear
weapons to biological weapons was a strategic act on the part of biodefense advocates.
45 The EIS was founded in 1951 by Alexander Langmuir. For Henderson’s recollections, see D. A. Henderson,
Smallpox: The Death of a Disease (New York: Prometheus, 2009).
43
44
34
Alexander Langmuir, “The Surveillance of Communicable Diseases of National Importance,” New England
Journal of Medicine 268, 4 (24 Jan 1963): 182-3. As Lyle Fearnley has described, Langmuir pioneered a method of
epidemiological surveillance designed to track each instance of a disease within a given territory – one that
would serve the needs of both public health and biodefense. Lyle Fearnley, “’From Chaos to Controlled
Disorder:’ Syndromic Surveillance, Bioweapons, and the Pathological Future,” ARC Working Paper #5 (2005).
http://anthropos-lab.net/wp/publications/2007/08/workingpaperno5.pdf (accessed 2/2/2010)
47 Stephen Morse summarized the justification for developing such a network: “A global capability for
recognizing and responding to unexpected outbreaks of disease, by allowing the early identification and control
of disease outbreaks, would simultaneously buttress defenses against both disease and CBTW. This argues for
expanding permanent surveillance programs to detect outbreaks of disease.” Morse, “Epidemiologic
Surveillance for Investigating Chemical or Biological Warfare and for Improving Human Health,” Politics and the
Life Sciences 11, 1 (Feb. 1992): 29.
46
Haroon Ashraf, “David Heymann – WHO’s public health guru,” The Lancet Infectious Diseases 4, 12
(December 2004): 785 – 788.
48
Ibid., 787
David L. Heymann, “The international response to the outbreak of SARS in 2003,” Philosophical Transactions of
the Royal Society of London B 359 (2004): 1127.
51 See Garrett, The Coming Plague.
52 Lorna Weir, and Eric Mykhalovskiy “The Geopolitics of Global Public Health Surveillance in the 21st
Century, in Alison Bashford, ed., Medicine at the Border: Disease, Globalization, and Security, 1850 – Present
(Basingstoke and New York: Palgrave MacMillan, 2007): 240-263.
53 David Fidler, “From International Sanitary Conventions to Global Health Security: The New International
Health Regulations,” Chinese Journal of International Law 4, 2 (2005): 353.
54 Claire Hooker, “Drawing the Lines: Danger and Risk in the Age of SARS,” in Alison Bashford, ed., Medicine
at the Border: Disease, Globalization, and Security, 1850 – Present (Basingstoke and New York: Palgrave MacMillan,
2007).
55 Ashraf, “David Heymann,” 787
56 Heymann, “International Response,” 1128.
49
50
Howard Markel, Lawrence O. Gostin and David P. Fidler, “Extensively Drug-Resistant Tuberculosis: An
Isolation Order, Public Health Powers, and Global Crisis,” JAMA 298, 1 (July 4, 2007): 83 – 86.
57
John Schwartz, “Tangle of Conflicting Accounts in TB Patient’s Odyssey,” New York Times, June 2, 2007.
“Editorial: TB Terror,” Los Angeles Times, June 10, 2007.
60 Committee on Homeland Security, The 2007 XDR-TB Incident: A Breakdown at the Intersection of Homeland
Security and Public Health, (Washington, D.C.: U.S. House of Representatives, 2007), p. 2.
61 As an example we can take the recent $33 million dollar initiative by the Gates foundation, in collaboration
with the Chinese Ministry of Health, to develop a quick diagnostic test for drug resistant TB. Sandi Doughton,
“Gates Foundation Launches 3rd Initiative in China,” Seattle Times, March 31, 2009.
62 John Donnelly, “Specialists say TB case a sign of things to come,” Boston Globe, June 4, 2007.
63 See, for example, Paul Farmer, Infections and Inequalities: The Modern Plagues (Berkeley: University of California
Press, 2001).
64 Fidler, “From International Sanitary Conventions,” 389.
65 Ibid., 391
66 Philippe Calain, “From the field side of the binoculars: a different view on global public health surveillance,”
Health Policy and Planning 22, 1 (2007): 19.
67 Veronique Martinache, “Swine flu: rich nations' spending spurs ethics row,” AFP, August 1, 2009.
58
59
Rob Stein, “Millions of H1N1 vaccine doses may have to be discarded,” Washington Post, April 1, 2010.
Anne Chaon, “France joins Europe flu vaccine sell-off,” AFP, January, 3, 2010.
70 Jeanne Whalen and David Guthier-Villars, “European Governments Cancel Vaccine Orders,” Wall Street
Journal, January 13, 2010.
68
69
35